Covid 19 Intake Form

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Full Name

Date of Birth

Email

Phone

Appointment Date *

Please complete this not sooner than 24 hours before the session.

Appointment Time *

Have you, or anyone in your household, had a fever in the last 14 days of 100 degrees Fahrenheit or above?

• Yes
• No

Have you, or anyone in your household, within the last 14 days, had any respiratory or flu symptoms, cough, sore throat, shortness of breath or difficulty breathing?

• Yes
• No

Have you, or anyone in your household, been in contact with anyone in the last 14 days who has been diagnosed with Covid-19, has been exposed to Covid-19, or has coronavirus-type symptoms?

• Yes
• No

Have you, or anyone in your household, within the last 14 days, had any chills, fatigue, new head or body aches, new loss of taste or smell, or new rashes or lesions?

• Yes
• No

Have you, or anyone in your household, traveled outside of Vermont or hosted out-of-state visitors in the last 14 days?

• Yes
• No

Have you, or anyone in your household, tested positive for Covid-19 (and consider yourself recovered) or do you strongly suspect you may have had Covid-19 (and consider yourself recovered)?

• Yes
• No

Have you engaged in any higher risk activities (inside, unmasked, crowded) in the last 14 days? Examples: an indoor gathering of folks outside of your immediate household and existing "bubble", eating inside at a restaurant, an indoor exercise class, a large party (over 10 people inside or over 25 people outside), etc. *

• Yes
• No

What is your temperature today?

Name

Submit